<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198202959
Report Date: 11/03/2023
Date Signed: 11/03/2023 12:15:09 PM


Document Has Been Signed on 11/03/2023 12:15 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:MOONLIGHT GARDEN RESIDENTIAL FACILITY FOR ELDERLYFACILITY NUMBER:
198202959
ADMINISTRATOR:MOZHGAN MOJABFACILITY TYPE:
740
ADDRESS:3670 BARRY AVE.TELEPHONE:
(310) 621-4595
CITY:LOS ANGELESSTATE: CAZIP CODE:
90066
CAPACITY:6CENSUS: 0DATE:
11/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:06 AM
MET WITH:Mozhgan Mojab, AdministratorTIME COMPLETED:
12:49 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/03/2023 at 8:03 am Licensing Program Analyst (LPA) David España conducted an unannounced Annual Required - 1 Year visit. LPA was met by Mozhgan Mojab, Administrator and the purpose of today’s visit was explained. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access and allowed to enter the facility to conduct inspections.

The purpose of today’s visit was to conduct the annual inspection. LPA met with the Licensee, Mozhgan Mojab. The facility is a Residential Care Facilities for the Elderly (RCFE) and licensed to serves clients age range 60 and over, four (4) non-ambulatory (only on three front bedrooms of house).The facility currently has zero (0) residents residing at the facility. LPA toured the physical plant and ensured that there were no residents residing in the facility. The home consists of four (4) bedrooms, three and half (3 1/2) bathrooms, two (2) living room, one (1) dining room, and one (1) kitchen.

Bedrooms had the required furniture, bed linens and closet/drawer space to accommodate residents. Bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew. Water temperature properly measured between 105 – 120 degrees Fahrenheit. Bath towels and toiletries were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. All doors have auditory alarms. LPA verified that the facility has an approved mitigation plan report. Kitchen was checked and observed to be within Title 22 regulations. LPA toured the kitchen area and observed a two-day (2) supply of perishable and a seven-day (7) supply of non-perishable food. Knives and toxics were kept in locked storage cabinets. Smoke detectors were working properly. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. Continued on LIC 809-C.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: MOONLIGHT GARDEN RESIDENTIAL FACILITY FOR ELDERLY
FACILITY NUMBER: 198202959
VISIT DATE: 11/03/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
There were three (3) Technical Assistance notes issued on 11/03/2023:
  1. Resident Rights/Information - Technical Assistance: 87468(c)(2)(A)
  2. Employee Rights - Technical Assistance: 87412(a)
  3. Disaster Preparedness - Technical Assistance: 1569.695(a)(5)

No deficiencies cited during this visit.

Exit interview conducted and a copy of this report and appeals rights were provided to Mozhgan Mojab.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: David EspanaTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5